Provider Demographics
NPI:1801264684
Name:MOBERLY, MARLA
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:MOBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 GRANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:156 GRANVILLE ST
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6505
Practice Address - Country:US
Practice Address - Phone:614-470-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10077225200000X
TX2115045225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant